In Network vs. Out of Network Providers: What’s the Difference?

Knowing your health plan can help you save money and avoid surprise expenses. Understanding in-network vs. out-of-network providers is key to learning how your health plan works. The providers you see can greatly impact how much your health plan covers for the visit and the negotiated rate you’ll be left paying. Familiarize yourself with this aspect of your health insurance now to maximize the financial benefits you experience from your health plan.

What Is a Health Care Provider?

A health care provider is an individual or entity that treats patients or offers medical treatments. This includes a wide range of medical professionals.

• Nurses
• Doctors
• Midwives
• Labs
• Hospitals
• Midwives
• Urgent care facilities
• Medical supply companies
• Physical therapists
• Home health providers
• Pharmacies

Health care providers are not insurance plans or the insurance company. These plans administrate paying for care but they do not provide the care. 

What Is “In Network” Provider?

An in-network provider is a doctor or medical facility contracted with your health insurance to provide services at an agreed-upon price. Providers not under contract with your health insurance plan are out-of-network providers.

How much you pay out-of-pocket for an out-of-network provider will vary based on your health insurance. Some cover none of the expenses for these providers. Others cover them but at a smaller percentage than in-network providers. For example, your health plan might cover an in-network doctor visit at 80% and an out-of-network doctor visit at 60%. While that might not sound like a lot of money, the difference is significant when you get into specialists, procedures and hospital visits.

Most health plans provide an online database of in-network providers so you can find someone in your area who can fulfill the specialties you’re seeking. You can filter results based on distance, specialty, languages the provider speaks, and more. If you can’t find this searchable database, contact customer service for your health plan to learn where this information is held.

When you call to make an appointment with your provider, state your insurance coverage and ensure they work with that insurance company. Sometimes, providers change accepted insurance companies, but those changes don’t quickly make their way to the online databases.

How Much Does It Cost to Use In-Network Providers?

The cost of seeing in-network providers varies based on your health insurance and the visit or procedure you’re at the office for, where you’re at in meeting your deductible, your health plan’s copays, etc. 

The average cost for a primary care doctor’s visit is $171 nationwide. If your health insurance covers in-network visits at 80%, your visit will cost $34.20, assuming you’ve met your deductible or that your health plan has no deductible.

Every health plan handles how much it covers differently. Review your health plan coverage before deciding whether seeing in-network providers is worthwhile.

Pros and Cons

Seeing in-network providers will mostly benefit you. However, review the pros and cons to ensure you know what you’re committing to when selecting these doctors.

What Is “Out of Network Provider?”

An out-of-network provider is a doctor, nurse or facility with no contract to provide services with your health plan. These providers have not signed an agreement to work with your insurer. 

Generally, this results in higher costs up to the full cost of the services you’re seeking. Some health plans cover a portion of out-of-network expenses while others pay nothing. 

Review your health plan’s providers and ask when booking the appointment whether the provider accepts your insurance. This will help you make an informed decision about whether to work with an out-of-network provider.

How Much Does It Cost to Use Out of Network Providers?

The cost of seeing out-of-network providers will vary based on your unique health plan coverage. However, you’ll pay more than you would to see in-network providers.

For example, if your health plan covers 80% of in-network providers and 60% of out-of-network providers and you need a $1,000 procedure, your portion of that procedure will cost $200 more with an out-of-network provider.

Another cost of seeing an out-of-network provider is the possibility that you must handle the billing process. Some out-of-network providers won’t bill health plans they don’t have a relationship with. That means you’ll pay the full price of seeing that provider and then need to submit documentation to your health plan for possible reimbursement. Other providers will still bill your insurance first. Ask about this process before seeing an out-of-network provider to ensure you’re up for the time commitment of handling billing yourself and have the funds to pay for the service upfront.

Pros and Cons

While you won’t get as much financial benefit from seeing out-of-network providers, you should still weigh the pros and cons of seeing the medical providers with whom you have built a relationship.

Tips on Taking Advantage of Out of Network Providers

At times, you can’t avoid seeing out-of-network providers. Perhaps no one in your area has the specialty you need to see on your health plan. Or you’re looking to get a second opinion before moving forward with a procedure.

Regardless of why you must see an out-of-network provider, review these tips to spend as little as possible out of pocket.

Check if Out-Network Provider Offers Discounts

Ask about discounts before booking your appointment. For example, you might enjoy lower costs for paying cash upfront rather than waiting for them to bill your health insurance. Other providers offer discounts for members of certain clubs or groups. If you don’t have the cash to pay for the services, the provider might still provide a discount if you agree to a shorter repayment timeline. Regardless of whether the provider offers discounts, ask about affordable tools for managing the cost of care. 

Choose a Health Insurance Plan That Offers Out-of-Network Benefits 

If you have health plan options at your employer or are evaluating your options to purchase an individual plan, consider selecting one with out-of-network benefits. This is a good idea even if you don’t currently have providers out-of-network that you want to keep seeing. You never know when a provider will change the insurance plans it accepts and you’ll be left with the choice of finding a new provider or paying out of pocket.

You’ll still pay more for out-of-network providers but still have some coverage to help offset the expense.

Ask for Assistance From Your Insurance Company

You can argue that you need to see an out-of-network provider. Your provider can help you demonstrate medical necessity, such as in an emergency or a complex condition that requires a unique specialty. There’s no guarantee that the health plan will pay for the service, but it’s always worth trying. And if it does pay for the service, you’ll still need to cover your portion.

PPO vs. HMO Networks

Different types of health insurance plans handle provider networks differently. A preferred provider organization (PPO) offers healthcare providers contracted at a certain rate. However, you can still seek care from out-of-network providers and receive some coverage for those services.

A health maintenance organization (HMO) assembles a network of doctors and other healthcare organizations willing to complete services at a set rate. This helps the HMO manage costs for its members. However, it also means you’ll have no coverage for out-of-network providers. 

While PPOs generally result in higher expenses for the insured, they offer greater flexibility in who to see. HMOs provide low rates but strict rules for who can be seen.

Compare the Best Health Insurance Plans From Benzinga’s Top Providers

Review these leading health plans to find the best health insurance for both in-network and out-of-network providers.

Managing Health Care Expenses with In-network Providers

The more in-network providers you see, the greater benefit you’ll get from your health plan. While it can be frustrating to find new providers when changing health plans or when a provider stops contracting with your health plan, staying within your health plan’s network is a wise way to manage expenses.

Frequently Asked Questions